clinical study emergent intervention criterias for controlling...

Hindawi Publishing CorporationISRN UrologyVolume 2013, Article ID 760272, 4 pageshttp://dx.doi.org/10.1155/2013/760272

Clinical StudyEmergent Intervention Criterias for Controlling SeverBleeding after Percutaneous Nephrolithotomy

Ural Oguz,1 Berkan Resorlu,1 Mirze Bayindir,1 Tolga Sahin,1

Omer Faruk Bozkurt,1 and Ali Unsal2

1 Department of Urology, Kecioren Training and Research Hospital, Ankara, Turkey2Department of Urology, Gazi University School of Medicine, Ankara, Turkey

Correspondence should be addressed to Ural Oguz; [email protected]

Received 27 May 2013; Accepted 8 July 2013

Academic Editors: A. M. El-Assmy, C. D. Lallas, and D. Minardi

Copyright © 2013 Ural Oguz et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objectives. To determine when emergent intervention for bleeding after percutaneous nephrolithotomy (PCNL) is required.Methods. We reviewed analysis data of 850 patients who had undergone PCNL in our center. Blood transfusion was needed for60 (7%) patients during and/or after surgery. We routinely performed followup of the urine output per hour, blood pressure, andhemoglobin levels after PCNL. Five (0.6%) of them had severe bleeding that emergent intervention was needed. Results. The meanage of the 5 patients who had emergent surgery due to severe bleeding was 42.2 (19–56) years. Mean duration of surgery was44.75 (25–65)minutes. Mean stone size was 27 (15–38)mm. Mean decrease of hemoglobin was 4.8 (3.4–5.8) ng/dL, and unit oftransfused blood was 4.4 (3–6). Mean blood pH was 7.21. There were metabolic acidosis and anuria/oliguria in all these patients.One of 5 patients suffered from cardiopulmonary arrest because of massive bleeding four hours after the PCNL, and despite cardiacresuscitation, he died. Hemorrhaging was controlled by open surgery in the other 4 patients. Two patients experienced cardiacarrest during the open surgery but they responded to cardiac resuscitation. There were no metabolic asidosis and anuria/oliguria,and bleeding was managed only with blood transfusion for the other 55 patients. Conclusion. Severe bleeding after PCNL is rareand can be mortal. If metabolic asidosis and anuria/oliguria accompanied the drop of hemoglobin, emergent surgical interventionshould be performed because vascular collapse may follow, and it may be too difficult to stabilise the patient.

1. Introduction

Urolithiasis is a common disease, and the prevalenceof this disease is increasing everyday [1]. Percutaneousnephrolithotomy (PCNL) is an effective and common treat-ment technique for especially large and complex renalcalculi. Although PCNL is a common procedure, it canbe associated with some mortal or morbid complicationssuch as septicemia, severe bleeding, and pleural or colonicinjury. With this study, we documented patients who neededblood transfusion and patients who had renal hemorrhagingrequiring emergent intervention after PCNL. We aimed toanswer questions including “how long conservative therapyfor bleeding after PCNL takes?” and “when emergent inter-vention should be performed?” To our knowledge, this is thefirst paper to investigate this topic regarding PCNL.

2. Material and Methods

2.1. Patients. We performed a retrospective analysis of 850patients who underwent PCNL in the urology departmentof our institute. Before the operation, patients were eval-uated with abdominal X-ray, ultrasonography, intravenousurography (IVU), and/or computerized tomography. Bloodsamples were analyzed for serum biochemistry, completeblood count, and coagulation tests. Urinalysis and urineculture were also analyzed. All patients were instructed notto use antithrombotic or antiagregan agents like aspirin for atleast 1 week before the procedure.

2.2. Surgical Technique. The PCNL operation was performedfollowing the standard procedure, starting with the insertionof a ureteral catheter in the lithotomy position. The surgeon

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continued the operation with the patient in a supine orprone position. Percutaneous access was performed underfluoroscopic guidance by the urologist. Tract dilation wasachieved by Amplatz, metal, or balloon dilators. 11-F, 15.9-F, 22-F, or 26-F rigid nephroscopes were used. Stone frag-mentation was performed using pneumatic and ultrasoundenergy. In some cases, a holmium laser was used with aflexible nephroscope for stones which were impossible toreach with a rigid nephroscope. Mostly, a nephrostomy tubewas placed at the end of the operation and removed after 1 to 3days. Tubeless procedurewas performed for selected patients.Patients were discharged when there was no leakage detectedin the nephrostomy tract.

2.3. Postoperative Followup. In our clinic, we check thehemoglobin immediately following PCNL and again 24 hourslater in all patients. If necessary, checks were performed atmore frequent intervals. We also routinely perform followupof the urine output per hour after PCNL. If anuria oroliguria is detected, we focus on the vital signs like bloodpressure, pulse, and we check the blood count and blood gasanalysis for metabolic acidosis. Anuria/oliguria and decreaseof hemoglobin could disappear with the fluid resuscitationand blood transfusion or could not. But in case of metabolicasidosis associated with anuria/oliguria and decrease ofhemoglobin, emergent surgical intervention was needed.

3. Results

Blood transfusion was necessary for 60 (7%) patients. Five ofthemhad severe bleeding that emergent open explorationwasneeded. Bleeding was self-limited, and blood transfusion wasenough for other 55 patients.

For those 55 patients, male/female ratio was 3/4. Meanpatient age was 45 (1–76) years; median patient age was 49years. Twenty-six patients had the operation on the rightside, while 29 had the operation on the left side. Seven (11%)patients had more than 1 access, while others had 1 access.The number of upper pole access was 9, middle pole accesswas 11, and lower pole access was 42. Mean operation timewas 84.91 (25–170) minutes. Mean stone size was 39.87 (15–99)mm. Mean decrease of hemoglobin was 3.98 (1–7.6) g/dL,and mean blood transfusion ratio was 1.77 (0.25–7) units.Mean hospitalisation time was 5.4 (3–14) days (Table 1).

Nineteen of the 60 patients who needed blood transfu-sions had anuria or oliguria with a decrease of hemoglobin.Of these 19 patients, metabolic asidosis, however, wasdetected in only 5.

Of these 5 patients who needed emergent intervention,one patient died, and four of them underwent renal explo-ration following the first 24 h of PCNL. The patient whodied due to severe bleeding had paraplegia because of aroad accident and had the history of open nephrolithotomysurgery. The other four patients had no comorbidity beforethe operation. Mean time between PCNL and interventionwas 13 hours. Mean duration of PCNL surgery was 44.75 (25–65) minutes. Mean stone size was 27 (15–38)mm. All hadlower pole access, andAmplats dilators were used for the tract

dilation in all patients. Four patients had the operation onthe left side, while one had the operation on the right side.Mean drop of hemoglobin for these 5 patients was 4.8 (3.4–5.8) g/dL. Mean blood transfusion ratio was 4.4 (3–6) units.Mean blood pH was 7.21. They all had metabolic asidosisand anuria/oliguria with drop of hemoglobin. Of thesepatients, one suffered from cardiopulmonary arrest becauseof massive hemorrhaging four hours after the operation.There was not enough time for intervention, and despitecardiac resuscitation, the patient had died. In the other4 patients, hemorrhaging was controlled by open surgerybecause immediate embolization was not available. Twoof these patients suffered from cardiac arrest during theopen surgery, but they responded to cardiac resuscitation.Characteristics of these 5 patients are shown in Table 2.

The next finding after a decrease of hemoglobin wasanuria or oliguria. However, if there was a metabolic asidosisin the blood gas analysis, transfusion was not enough tokeep the patients stable. So, from anuria/oliguria, situationprogressed to metabolic asidosis. Another important findingfor these patients was the appearance of vascular collapse,detected after metabolic asidosis.

Because we did not have an angiography unit in ourinstitute, we performed open surgery for this emergentsituation.We observed that there was not any injury to vesselsand bleeding was from the dilation tract. We controlled thebleeding by primer suturation in all patients. There was ahematoma around the kidney in retroperitoneum, and thepatients became stable dramatically just after removing thehematoma.

We detected arteriovenous fistula in 3 (0.3%) patients andpseudoaneurysm in 2 (0.2%) patients after the procedure asa late bleeding, and these patients were treated with electiveembolization successfully. These late bleedings were not life-threatening.

4. Discussion

Urolithiasis is a common disease, and percutaneous nephro-lithotomy (PCNL) is an effective treatment for especially largeand complex renal calculi. PCNL has become a commonprocedure since it was described in 1976 [2]. Although PCNLis a commonprocedure, it can be associatedwith somemortalormorbit complications.There are some studies investigatingthe prediction of morbidity and mortality of this surgery [3–5]. The complication rate of PCNL is up to 83%, but theyare generally minor complications [6]. Renal hemorrhagingrequiring intervention is a rare complication of PCNL, and itsfrequency is 0.6–1.4% [6]. In our series, 1.17% of the patientsneeded intervention for renal hemorrhaging, and half ofthem (0.58%) had emergent surgical intervention.

Renal hemorrhage is generally associated with thenephrostomy tract, operative time, method of tract dilatationand access guidance, number of tract, renal parenchymalthickness, absence of hydronephrosis, intraoperative punc-ture time, size and location of stones, upper calyceal access,extensive angulation with rigid nephroscope, diabetes mel-litus, and the experience of surgeon [7–12]. During PCNL a

ISRN Urology 3

Table 1: Characteristics of patients who had bleeding and blood transfusion.

Gender(M/F)

Age(year)

Meanstone size(mm)

Operationtime

(minute)

Access(lower/middle/upper pole)

Meanhemoglobin

(preop/postop)

Mean bloodtransfusion

(unit)

Anuria/oliguria

(𝑛)

Meanblood pH

Hospitalisationtime (day)

Patients treatedwith bloodtransfusion(n: 55)

24/31 45(1–76)

39.87(15–99)

84.91(25–120) 42/11/9 12.98/9.03 1.77

(0.25–7) 14 7.36(7.33–7.42) 5.3 (3–14)

Patients neededemergentintervention(n: 5)

5/— 42.2(19–56)

27(15–38)

44.75(25–65) 5/—/— 13.3/8.7 4.4 (3–6) 5 7.21

(7.20–7.25) 7.75 (5–10)

Table 2: Characteristics of patients who needed emergent open surgical exploration for bleeding after percutaneous nephrolithotomy.

Gender Age (year) AccessTime betweenPCNL and

intervention (h)Blood pH Hemoglobin

(preop/postop)

Eritrosittransfusion

(unit)

Hospitalisation(day)

M 41 Subcostal lower pole 10 7.25 12.2/8.8 6 5M 56 Subcostal lower pole 6 7.23 12.3/7.7 4 10M 40 Subcostal lower pole 12 7.20 14.2/9.8 3 9M 19 Subcostal lower pole 24 7.20 14.4/8.6 5 7M 55 Subcostal lower pole 4 7.20 13.4/8.6 4 ex

grade IV renal injury occurs, and bleeding can appear duringevery step of the operation. Decrease of hemoglobin can beseen after all PCNL operations; however, this is generallyself-limited because of the restrictive effect of the Gerota’sfascia and retroperitoneum. Therefore, bleeding is oftencontrolled by conservativemeasures likemonitoring the levelof hemoglobin and vital signs with fluid resuscitation therapyor sometimes a blood transfusion. That is why PCNL is alsoa safe procedure for selected patients using anticoagulanttherapy [13].

In the literature, blood transfusion rate was reported as4.9% to 9.5% [4, 14]. In our series, blood transfusion rate is7%. Arteriovenous fistula was detected in 3 (0.3%) patientspseudoaneurysm in 2 (0.2%) patients in 7 to 15 days afterthe PCNL, and they were treated by embolisation. Severebleeding occurred in 5 patients. One patient died becauseof severe hemorrhaging immediately after the operation.Four patients needed emergent open surgical explorationafter the operation. The main triads for requiring emergencyintervention were decrease of hemoglobin, anuria/oliguria,and metabolic asidosis.

Anuria or oliguria with a decrease of hemoglobin wasdetected in 19 of 60 patients (31.6%) who had blood trans-fusions. Of 19 patients, metabolic asidosis was detected in 5,and these 5 patientswere thosewhoneeded emergent surgicalexploration. Metabolic asidosis was not detected in the otherpatients. Vasculary collapse is the next step after metabolicasidosis.

Bleeding can be an important complication as it has beendescribed in our study. It is important to make decisions foremergent surgery to control bleeding after PCNL.Onepatientdied, and 2 patients had cardiac arrest after the surgery. We

determined that surgical intervention for patients who hadthe triad mentioned above is essential, and if intervention ispostponed, the risk of vascular collapse is extreme.

5. Conclusion

Although PCNL is a safe procedure for the treatment of renalcalculus, it sometimes results in some complications. Bleed-ing after PCNL is generally self-limited and can be treatedwith conservative measurements. However, it is importantto determine the time for emergent intervention. If thedecrease of hemoglobin is associatedwith anuria/oliguria andmetabolic asidosis, emergent surgical intervention should beperformed before vasculary collapse.

Conflict of Interests

The authors declare that they have no conflict of interests.

References

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[2] I. Fernstrom and B. Johansson, “Percutaneous pyelolithotomy.A new extraction technique,” Scandinavian Journal of Urologyand Nephrology, vol. 10, pp. 257–259, 1976.

[3] A. Tefekli, M. A. Karadag, K. Tepeler et al., “Classification ofpercutaneous nephrolithotomy complications using the modi-fied Clavien Grading system: looking for a standard,” EuropeanUrology, vol. 53, no. 1, pp. 184–190, 2008.

4 ISRN Urology

[4] A. Unsal, B. Resorlu, A. F. Atmaca et al., “Prediction ofmorbidity and mortality after percutaneous nephrolithotomyby using the Charlson Comorbidity Index,”Urology, vol. 79, no.1, pp. 55–60, 2012.

[5] B. Resorlu, A. Diri, A. F. Atmaca et al., “Can we avoid percuta-neous nephrolithotomy in high-risk elderly patients using theCharlson comorbidity index?” Urology, vol. 79, no. 5, pp. 1042–1047, 2012.

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[7] R. Kukreja, M. Desai, S. Patel, S. Bapat, and M. Desai, “Factorsaffecting blood loss during percutaneous nephrolithotomy:prospective study,” Journal of Endourology, vol. 18, no. 8, pp. 715–722, 2004.

[8] B. Turna, O. Nazli, S. Demiryoguran, R. Mammadov, and C.Cal, “Percutaneous nephrolithotomy: variables that influencehemorrhage,” Urology, vol. 69, no. 4, pp. 603–607, 2007.

[9] A. R. El-Nahas, A. A. Shokeir, A. M. El-Assmy et al., “Post-percutaneous nephrolithotomy extensive hemorrhage: a studyof risk factors,” Journal of Urology, vol. 177, no. 2, pp. 576–579,2007.

[10] F. Kurtulus, A. Fazlioglu, Z. Tandogdu, S. Karaca, Y. Salman,and M. Cek, “Analysis of factors related with bleeding inpercutaneous nephrolithotomy using balloon dilatation,” TheCanadian Journal of Urology, vol. 17, no. 6, pp. 5483–5489, 2010.

[11] T. Akman, M. Binbay, E. Sari et al., “Factors affecting bleedingduring percutaneous nephrolithotomy: single surgeon experi-ence,” Journal of Endourology, vol. 25, no. 2, pp. 327–333, 2011.

[12] Y. Wang, Y. Wang, F. Jiang et al., “Post-percutaneousnephrolithotomy septic shock and severe hemorrhage: astudy of risk factors,” Urologia Internationalis, vol. 88, no. 3, pp.307–310, 2012.

[13] J. C. Kefer, B. Turna, R. J. Stein, and M. M. Desai, “Safetyand efficacy of percutaneous nephrostolithotomy in patients onanticoagulant therapy,” Journal of Urology, vol. 181, no. 1, pp.144–148, 2009.

[14] T. Lopes, K. Sangam, P. Alken et al., “The clinical research officeof the endourological society percutaneous nephrolithotomyglobal study: tract dilation comparisons in 5537 patients,”Journal of Endourology, vol. 25, no. 5, pp. 755–762, 2011.

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